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PATIENT HISTORY FORM
DATE TODAY:
WE STRIVE TO KEEPALL INFORMATION IN CONFIDENCE AND WILL NOT RELEASE WITHOUT SIGNED CONSENT. It may be
sent to consultants, if referred.
NAME:
Birth date:
LAST
FIRST
M.I.
MARITAL STATUS: ( ) SINGLE; ( ) MARRIED; ( ) WIDOWED; ( ) SEPARATED; ( ) DIVORCED
AGE:
OCCUPATION:
REASON FOR VISIT TODAY:
LAST MEDICAL EXAM:
LAST CHEST X-RAY (Date and location):
LAST DOCTOR:
ALLERGIES (DRUGS, X-RAY DYE, TAPE, LATEX) & type of reaction:
PHARMACY NAME & PHONE #:
MEDICATIONS: (LIST ALL MEDICATIONS, INCLUDING THOSE NOT PRESCRIBED, SUCH AS ALTERNATIVE
AGENTS OR HERBAL AGENTS).
HOW OFTEN YOU
LENGTH OF TIME
DRUG
STRENGTH
TAKE PER DAY
YOU HAVE TAKEN
i.e.: Advil
200 mg
3 times per day
6 months
Please know what drugs and doses you take; if you need refills let the nurse know when she places you in the exam room.
CHILDHOOD ILLNESSES: Chicken Pox ( ) Measles/Rubeola ( )
Mumps ( )
Rubella ( )
Scarlet fever ( )
PREVIOUS MEDICAL ILLNESS/HOSPITALIZATION (other than under surgery):
*If Diabetic, do you self-test with glucose meter?
Do you get yearly eye exams?
course?
Do you know what to do for low blood sugar?
Foot care?
Have you been to a self- management
HgbA1C current value?
SURGERY: (IF YES, PLEASE CHECK ( ) AND GIVE APPROXIMATE DATE IN BLANK SPACE)
(
(
(
(
)Appendectomy
)Breast Biopsy
)Carotid artery
)Cataracts
OB/GYN History:
(
(
(
(
)C-Section
)Gallbladder
)Heart angioplasty
)Heart bypass
Pregnancies: #
Deliveries: #
(
(
(
(
)Hernia repair
)Hysterectomy
)Mastectomy
)Prostate removal
( )Ovary: R
( )Stomach surgery
( )Tonsillectomy
L
Last menstrual cycle:
**Check X if YES, or write “NO” in front of the items below:
Tobacco use
# of packs per day:
# of years:
Are you interested in stopping? Yes
No
Tobacco use in past
When did you stop?
If you continue to smoke, exercise regularly! When ready to stop, call if you want help
Alcohol use Beer
Wine
Liquor
ounces/glasses/cans per week on average):
Caffeine use
Coffee:
*** Do not mix drinking and driving please. ***
cups per day
Sodas:
cans/ounces per day:
Exercise
Type:
Times per week:
*** Goal of 30 minutes of walking-type exercise 5 days per week recommended. ***
form.A-05.Patient.History.14430 Rev. (04/08)
PATIENT HISTORY FORM
DATE
NAME:
Last
First
M.I.
Date of Birth
FAMILY HISTORY: Place an “X” in the space next to the condition that your family member has, then specify their relation to you
after the condition, using the following abbreviations:
Mother (M); Father (F); Brother (B); Sister (S); Grandparent (GP); Aunt (A); Uncle (U)
For example, if your Aunt and Mother had breast cancer: ( X ) Breast Cancer A, M
( ) Alcoholism
( ) Colon Polyps
( ) High Blood Pressure
( ) Prostate cancer
( ) Anemia
( ) Colon cancer
( ) Iron Disease
( ) Seizures
( ) Asthma
( ) Diabetes
( ) Kidney Disease
( ) Thyroid disease
( ) Arthritis
( ) Glaucoma
( ) Mental Illness
( ) Tuberculosis
( ) Bleed easily
( ) Gout
( ) Migraine
( ) Breast Cancer
( ) Heart Disease
( )Osteoporosis
LIVING
FATHER ( ) Yes (
MOTHER ( ) Yes (
SIBLING ( ) Yes (
SIBLING ( ) Yes (
AGE OR AGE ATDEATH.
Present health or cause of death
) No
) No
) No
) No
Immunizations: (Please check the disease against which you have been immunized and date of last booster.) Tetanus or Td
booster is due every 10 years. Let the nurse know if you are due for a booster.
( ) Hepatitis B
( ) Tetanus
( ) Measles/Mumps/Rubella
( ) Pneumonia
( )Heapatitis A
( ) D.T. (Diphtheria/Tetanus)
( ) Varicella
( )Flu Vaccine
( ) Meningitis vaccine
***If you have Hepatitis C or chronic liver disease, talk to your doctor about keeping up to date with your shots. You may benefit from
Hepatitis A or B vaccine, or even the Pneumonia shot.
***If you have lung disease, keep up to date with the Influenza and Pneumonia shots.
Illicit Drugs Use? Please discuss with your physician.
Risk factors for AIDS & Hepatitis B and C are the following. If any apply, please let your physician know during your visit. We will
observe confidentiality.
Blood transfusion; homosexual relations; IV drug use; relations with IV drug user; needle sticks; work with body fluids,
such as dental work, nursing, ER, etc.; sex with multiple partners.
Mark with an “X” if YES or write “NO”, for the following items.
Diet: Are you interested in information on diets for weight or cholesterol or diabetes?
Calcium intake: Do you know women need about 1000mg of calcium intake per day?
Bone Density tests: check if interested in information; considered after age 50 in women.
Colon exams: Did you know most experts recommend a colon exam every 5 years, after age 50? Please let us know if
you have a family history of colon cancer.
Mammography: recommended yearly in women after age 40; check if due for this test.
Safety Measures: Examples of action you can take are: Seat belts (every time), bicycle helmets (even adults), wrist protection during rollerblading, eye protection (weed-eating, power sawing, etc.), proper gun use (locking, unloading, keeping out of children’s access).
Advanced Directives: Please discuss with your spouse or family and your physician.
Living Will: No ( ) Yes ( )
Organ Donor: No ( ) Yes ( )
Durable Power of Attorney for Health Care: No ( ) Yes ( ) Who is your POA for Health Care?
A-10.form.HIPAA.Patient.Education.doc Rev. (04/08)
PATIENT HISTORY FORM
DATE
NAME:
Last
First
M.I.
Date of Birth
PLEASE PLACE A “Y” BY THE CURRENT COMPLAINT OR ALIMENT THAT APPLIES TO YOU, IF UNSURE, PLACE A QUESTION MARK “?”, IF IT
DOES NOT APPLY, PLACE AN “ N”.
HEAD
LUNGS
HEART
ABDOMEN
NEURO
BLURREDVISION
LAST EYE EXAM DATE
GLAUCOMA
FREQUENTHEADACHES
MIGRAINE HEADACHES
LUMPS OR SWELLING IN NECK
CONSTANTRINGING IN EARS
HEARINGPROBLEMS
FREQUENTEARACHES
FREQUENTNOSEBLEEDS
SINUS INFECTION
ALLERGIES/HAYFEVER
HOARSEVOICE, PERSISTENT
MOUTH OR TONGUE SORES
ASTHMA
HAVECOUGHEDUPBLOOD
INCREASING SHORTNESS OF BREATH
WITHACTIVITY
EMPHYSEMA
HISTORYOF TUBERCULOSIS
CHRONICCOUGH
FREQUENTIRREGULAR HEARTBEAT
CHEST PAIN OR TIGHTNESS IN CHEST
HEART MURMUR
Mitral valve prob.
HISTORYOF ENLARGED HEART
SHORTNESS OFBREATHAT NIGHT
SWELLING OF FEET, ANKLES PRESENT
AFTER SLEEP
HISTORYRHEUMATICFEVER
HIGHBLOODPRESSURE
PREVIOUS HEART ATTACK
FREQUENTHEARTBURN
DIFFICULTY OR PAIN IN SWALLOWING
HAVEVOMITEDBLOOD
RECTALPAINOR BLEEDING (BLACK
ORBLOODY)
RECENT CHANGE IN BOWEL HABITS
DIVERTICULITISor DIVERTICULOSIS
COLON POLYPS
Last Colon exam date:
HEPATITIS / YELLOW JAUNDICE/
LIVERDISEASE
NAUSEA
CONSTIPATION
DIARRHEA; how often per day
ABDOMINAL PAIN WITH Fatty Food
SUSPECTULCERS
HEMORRHOIDS
HISTORYOF ULCERS
BLEEDING
LOSS OFAPPETITE
SEIZURE
LOSS OF CONSIOUSNESS
DOUBLE VISION
MEMORYLOSS
KIDNEY
JOINTS
GENERAL
MALES
ONLY
FEMALES
ONLY
NUMBNESS OF HANDS OR FEET
NERVOUSNESSAFFECTING HOME LIFE OR WORK
SPEECHPROBLEMS
STROKE
RECURRENTURINARYTRACT INFECTION
URINATION ATNIGHT MORE THAN ONCE
BROWN, BLACK OR BLOODY URINE
BURNING ON URINATION
KIDNEYSTONES
DIFFICULTYSTARTING STREAM
PROBLEMS WITH SEXUAL FUNCTION
URINARYINCONTINENCE
BACKTROUBLE
SWOLLEN JOINTS
FREQUENTPAINFULFEET
FREQUENTSHOULDER PAIN
FREQUENT OR PERSISTENTACHING OF MUSCLES OR
JOINTS
GOUT
ARTHRITIS
OSTEOPOROSIS-How diagnosed?
DIABETES: Date diagnosed:
WEIGHT LOSS GREATER THAN 10 LBS IN LAST YR
LOSS OF INTEREST IN EATING
SLEEPINGDIFFICULTY
HERPES IN PAST-genital or face
THYROIDPROBLEMS
BLOODPRESSUREPROBLEMS
MOLE OR SORE NOT HEALING
HOT OR COLD NATURED
SUSPECT SERIOUS DISEASE OR CANCER
LEG CRAMPS WHILE WALKING
MORE THIRSTY LATELY
FATIGUE
FREQUENTCRYINGSPELLS,DEPRESSION
WORK OR FAMILYPROBLEMS
ANXIETY
ANEMIA
HIGH CHOLESTEROL & last result
WEAK URINE STREAM
PAINFULOR SORE GENITALS (PRIVATES)
PROSTATETROUBLE
HARD TO EMPTYBLADDER COMPLETELY
PERFORM SELF TESTICLE EXAM MONTHLY
LAST PSA TEST (if over age 50). DATE
LAST MENSTRUAL PERIOD
VAGINAL DISCHARGE OR PROBLEMS
PAINFULOR SORE GENITALS (PRIVATES)
LUMPS OR PAIN IN BREASTS
IFYOU SEE A GYNECOLOGIST, LISTNAME
Last Bone Density Test Date
LASTMAMMOGRAPHY Date
LAST PAPSMEAR Date
PERFORM SELF BREAST EXAM MONTHLY
A-10.form.HIPAA.Patient.Education.doc Rev. (04/08)